Objective portion
Posted By: LG on 2007-10-16
In Reply to:
Subject: Objective portion
does this make sense to anyone
GU and rectum s/l farum are rectal sphincter muscle tone
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Listening again, it almost s/l folded portion/fulton portion. nm
Subject: Listening again, it almost s/l folded portion/fulton portion. nm
Please help with objective . . .
Subject: Please help with objective . . .
The wound has been cleaned by the nurse, and it looks very good. s/l Pride flesh is starting to form.
TIA for any suggestions!
a few hints for you - when doing the objective
Subject: a few hints for you - when doing the objective
findings, when doc says, for instance, "In general, the patient is..." you are putting that under the "general" subheading, so you don't need to repeat the "in general" part - meaning it would just be GENERAL: The patient is....
same with the skin exam that you have there - if doc is saying "skin is warm and dry," and you are putting it under the "skin" subheading, it should just be "SKIN: Warm and dry" ...and so on.
also, in the HEENT section, it should be "sclerae" and "conjunctivae" - doc is referring to the plural form here.
Does that make sense? This is the way it's usually done, but you'll need to follow the instructions you've been given, of course.
It's just under and Objective/General section
Subject: It's just under and Objective/General section
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though. 
OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
Subject: OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
diagnosis: Cerumen impaction.
Objective: Head is held straight with no s/l "lift or lisp"
Subject: Objective: Head is held straight with no s/l "lift or lisp"
anteromedial portion?
Subject: anteromedial portion?
Can't find it even with the entire sentence there.
is it possible that he says "a significant portion"?
Subject: is it possible that he says "a significant portion"?
Maybe lateral portion.
Subject: Maybe lateral portion.
macule portion is all I can think of right now. nm
Subject: macule portion is all I can think of right now. nm
Midportion or mid portion??
Help me! I get it corrected either way I type it . . which is correct?
Mid portion is what I usually type.
Subject: Mid portion is what I usually type.
midportion or mid-portion
Subject: midportion or mid-portion
x
the first and second portion of the duodenum
Subject: the first and second portion of the duodenum
sorry.....cartilaginous portion
Subject: sorry.....cartilaginous portion
typo mistake...
I keep them separate, i.e. mid portion.
Subject: I keep them separate, i.e. mid portion.
x
The sagittal portion of the exam...
Subject: The sagittal portion of the exam...
dd
Nooo! Never!! Just on the HEENT portion!!! nm
Subject: Nooo! Never!! Just on the HEENT portion!!! nm
Pickle portion of prostate?
Subject: Pickle portion of prostate?
Sentence: The prostatic urethra was patent with the exception of some regrowth of tissue near the s/l pickle portion of the prostate.
This is the second TURP for this patient. TIA
Looks fine but for mid portion being two words. nm
Subject: Looks fine but for mid portion being two words. nm
.
The "sidual" portion of the exam demonstrates
Subject: The "sidual" portion of the exam demonstrates
an oblique fracture of the mid shaft of the left femur.
Sidual or may "Decidual portion of the exam..."
I think rad is referring to portion of film that is at the very edge of the viewing screen.
Many thanks!
maybe "in portion"...poor English use, but a WAG. sm
Subject: maybe "in portion"...poor English use, but a WAG. sm
The "in" portion of the study as opposed to the "out" portion. Maybe he was talking slowly because he was...thinking..while...talking.... I've done that myself.
No time limits (usually) on transcription portion
Subject: No time limits (usually) on transcription portion
As far as posting test questions and waiting around for the answers, I would assume these questions were being asked about the transcription portion of the exam. Mind you, not all companies set a time limit for returning the transcription testing files to them. Tests I have taken in the past have been tough ones, as many as 4 parts, with testing time spanning a few days while waiting for the recruiter to grade each section.
*English grammar/punctuation skills. Pass this, you move on to the next.
*Medical terminology skills/medication uses/disease processes, etc. Pass this, advance again to the next.
*Transcription skills demonstrating all of the above plus your ear-ability. Pass this, whew...almost done with this testing stuff! On to the last step.
*Oral exam. Pass this, get an offer (hopefully for a lot more than 7 cpl considering ALL the testing you just passed). lol
Not all companies perform this kind of in-depth testing, but I think the ones that do are more interested in hiring an MT who will be able to taken off full QA within a day or two of being hired, as opposed to an MT that is not as familiar/experienced with this employ.
All moiety means is a part or portion so I would think
Subject: All moiety means is a part or portion so I would think
x
Tammie Tam, are you in the SKIN portion of ROS? If so, may be scabies?
Subject: Tammie Tam, are you in the SKIN portion of ROS? If so, may be scabies?
surgery: The s/l cartilized portion of the rib was resected.
Subject: surgery: The s/l cartilized portion of the rib was resected.
When typing words such as mid portion, mid transverse, etc. do you put them together such as
midportion, etc. etc. of keep them separated, mid portion and all other words that fall into this category.
ismet portion of the femoral canal
Subject: ismet portion of the femoral canal
Hi, does anyone know what (s/l) ismet is and how to spell it correctly?? Thanks!
prob..lateral portion tumor resection of the
Subject: prob..lateral portion tumor resection of the
right colon
Not sure about the "cat's" portion (though it would make sense, I guess), but .... sm
Subject: Not sure about the "cat's" portion (though it would make sense, I guess), but .... sm
..."cry" is likely correct, as I've often heard "uterine cry" in this context (and, frankly, I always thought it would be a great name for a Goth band:-).
Pt with learning disablities has taken the writing portion of the "viscut" or biscut". nm
Subject: Pt with learning disablities has taken the writing portion of the "viscut" or biscut". nm
Total shoulder arthroplasty. The inferior portion of the humeral head had
Subject: Total shoulder arthroplasty. The inferior portion of the humeral head had
s/l cuddle stellana and I took this down to bare bone and reamed getting down as concentric as possible.
In LAB portion: "a free T and a free T4"
Subject: In LAB portion: "a free T and a free T4"
I cannot find any just free T lab studies to be performed, and I am thinking he is leaving out the number after the T. I could be wrong though, so if anyone knows of there is a lab test of just a free T please post back and let me know.
Thanks so much in advance. 
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